Provider Demographics
NPI:1659192417
Name:JACKINS, TANYA NAN YOUNG
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:NAN YOUNG
Last Name:JACKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:NAN YOUNG
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 CRAFTSMAN DR NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-2639
Mailing Address - Country:US
Mailing Address - Phone:360-669-9479
Mailing Address - Fax:
Practice Address - Street 1:370 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3042
Practice Address - Country:US
Practice Address - Phone:360-748-6693
Practice Address - Fax:360-748-3619
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61620108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily